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A qualitative research synthesis examining the effectiveness of interventions used by occupational therapists in mental health |
Wimpenny K, Savin-Baden M, Cook C |
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CRD summary Occupational interventions providing space for healing, self-rediscovery, identity formation, and community participation, were valued more than short, psychological interventions, focused on case management and the assessment of mental stability. Occupational therapists should demonstrate an authentic therapeutic relationship built upon care, trust, and respect. The first conclusion was not fully supported by the evidence, but the second conclusion seems reliable. Authors' objectives To examine the effectiveness of occupational therapy in mental health service delivery, from the perspectives of clients and carers. Searching CINAHL, MEDLINE, PsycINFO, AMED, ASSIA, and Scopus were searched for international literature published in English from between 2000 and 2011. Search terms were not reported, and grey literature was excluded. Study selection Eligible for inclusion were peer-reviewed journal articles of qualitative studies focusing on the perspectives of adults or older people with mental health illness, or their carers, in relation to occupation-based interventions, occupational participation, or performance tasks. Interventions could be conducted in any setting. The included studies were conducted in various settings in the UK, Scandinavia, Australia, Canada, the USA, or the Netherlands. Intervention content varied (reported in the paper). Most perspectives were from adults, with a few from older people and carers. Some studies collected multiple perspectives (service users, carers, and occupational therapists). The outcomes were primarily process factors that were considered relevant to intervention success. Process factors included the capabilities of the therapist, the practice context, and the way in which the intervention was delivered. The authors referred to purposive sampling as the study selection method; no further detail was provided on this process, nor on how many reviewers were involved. Assessment of study quality Study quality was assessed using criteria adapted from Savin-Baden and Major (2007), covering seven dimensions (reported in the paper). Studies were scored according to the extent that each dimension was reported (no mention scored 0; some mention scored 1; good mention scored 2; and extensive mention scored 3). The authors did not state how many reviewers were involved in quality assessment. Data extraction Three reviewers were involved in data extraction and synthesis. Methods of synthesis Data extraction and synthesis followed a meta-ethnography approach, resulting in the development of first-, second-, and third-order interpretations of the data. Steering groups (of clients and occupational therapists) were established, alongside the research team, to discuss and critique the emergent findings. This resulted in continuous refinement to gather assurance on the congruence of themes. Results of the review Twenty-two studies were included in the review. Their quality was reported to be good (details not reported). Four inter-related themes for intervention effectiveness were identified. Professional artistry: This was the ability of the therapist to interact with clients, underpinned by sound professional reasoning, sometimes in the context of complex competing issues and discourses. Establishing legitimacy and building trust and responsiveness into client interactions was important, as was the therapist's ability to be reflective and pragmatic, with a strong commitment to professional values. Occupational engagement: Successful occupational engagement (where clients could fulfil their needs and wants, influenced by the physical and social environment) was characterised by the promotion of reflection, creativity, exploration and challenge, personal meaning, skill development, and self-confidence. This (the review authors stated) contrasts with mental health services that focus on short psychological or care-planning interventions. New horizons: In helping the client to move forward in relation to perceptions of themselves and their future, careful assessment by the therapist, to manage the challenge and pace of therapy, was considered to be an important factor. To support this, therapists had to take account of a number of factors, including client capacity and self-belief, social-cultural context, occupational gains, and working with resistance. Inclusion: The therapist role in facilitating environments to promote a sense of belonging and acceptance for the client was seen as an important part of a successful intervention. There were instances where cross-cultural situations presented complications that influenced the therapists reasoning, and conflicts arose, between the perspectives of carers and therapists, about beliefs and treatment options. Authors' conclusions Occupational interventions that provided space for healing, self-rediscovery, identity formation, and community participation, were valued more than short, psychological interventions, focused on case management and the assessment of mental stability. For interventions to have impact, occupational therapists needed demonstrate an authentic therapeutic relationship, built on care, trust, and respect. CRD commentary The review question was clear. The inclusion criteria were adequately specified; the perspective of health professionals included in the results was not defined before searching. The search included several sources, and the language restrictions were likely to be appropriate. The decision to exclude grey literature may mean that relevant studies were missed; grey literature can make an important contribution to reviews of qualitative studies. The processes of data extraction and synthesis were conducted with attempts to improve consistency, and the involvement of a steering group provided further assurance on the congruence of the findings. The process of study selection was unclear. Study characteristics were provided, but more information on the extent to which the evidence contributed to the three orders of interpretation, would have been helpful. Some inconsistent data were considered, and the reviewers appropriately acknowledged their professional perspective and its potential bearing on the synthesis. The first conclusion appears to be based on a comparison of interventions that was not fully substantiated by the evidence presented. The second conclusion is likely to be reliable. Implications of the review for practice and research Practice: The authors stated that workforce development was needed to ensure that occupational therapists use occupation-focused, and client experience-led outcomes as standard practice. Research: The authors stated that research should consider replicating or expanding programmes and partnerships to invest in the provision of occupation-focused interventions, with reference to the wider policy context and modernisation agenda for mental health in the UK and elsewhere. Therapists should capture, and report more clearly, their therapeutic effectiveness and cost-effectiveness. Funding Funded by a grant from the UK Occupational Therapy Research Foundation (UKOTRF). Bibliographic details Wimpenny K, Savin-Baden M, Cook C. A qualitative research synthesis examining the effectiveness of interventions used by occupational therapists in mental health. British Journal of Occupational Therapy 2014; 77(6): 276-288 Indexing Status Subject indexing assigned by CRD MeSH Humans; Mental Health Services; Occupational Therapy AccessionNumber 12014042300 Date bibliographic record published 24/10/2014 Date abstract record published 25/11/2014 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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